Provider Demographics
NPI:1659536522
Name:ECU PEDIATRIC DENTAL CLINIC
Entity Type:Organization
Organization Name:ECU PEDIATRIC DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE DEAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BENSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-744-7400
Mailing Address - Street 1:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:252-744-3520
Mailing Address - Fax:252-744-3194
Practice Address - Street 1:2150 HERBERT CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-3736
Practice Address - Country:US
Practice Address - Phone:252-744-3258
Practice Address - Fax:252-744-3194
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST CAROLINA UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-21
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0066122300000X, 1223P0221X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty